Clinical image: spondylodiscitis as a complication of urosepsis caused by extracorporeal shock wave lithotripsy for kidney stones

Extracorporeal shock wave lithotripsy (ESWL), a well-established treatment for urinary stones [1], is not free of complications [2]. This is the first report of spondylodiscitis following ESWL. A woman in her 70s had right renal colic for 3 months. On 9 December 2020, she consulted a urologist at a regional hospital. Clinical examination showed negative results, while abdominal ultrasound revealed a 16-mm right pyelic stone. Urinalysis performed on 12 December 2020 revealed leukocyturia and microhematuria. On 16 February 2021, the consentient patient underwent ESWL. The early post-operative course was uneventful. Thirtysix hours after the procedure, she experienced a fever with rigor and chills and progressive onset of lumbar pain. Home therapy with oral cefixime was unsuccessful, and she was re-admitted to the hospital 7 days after ESWL (23 February 2021). Increased white blood cells (11 600/μl), serum procalcitonin (19.84 ng/ml) and C-reactive protein (14.72 mg/dl) were detected. Hemoculture was positive for extended-spectrum beta-lactamases producing Escherichia coli, resistant to beta-lactamine and ciprofloxacin. Abdominal computerized tomography showed the unmodified stone. Hydronephrosis was not detected. Intravenous perfusion of gentamycin and co-trimoxazole allowed resolution of the sepsis in 5 days. The patient continued to take oral co-trimoxazole for a week after hospital discharge. In the meantime, the lumbar pain increased in intensity, which led her to consult a neurosurgeon at our university hospital. Magnetic resonance imaging (23 February 2021) showed spondylodiscitis at levels L3, L4, L5 (Fig. 1), which was treated with a cycle of parenteral antibiotics according to the modality described above. The patient was also fitted with an orthopedic brace, which gave complete relief of pain in 1 month. She was made aware of the possible occurrence over time of clinical and imaging features of lumbar stenosis as a consequence of vertebral and discs post-spondylodiscitis deformity. Weight loss and swimming were recommended. Eighteen months after ESWL, the patient was asymptomatic and presented only a modest limitation of lumbar spine motility. Regarding the stone, the patient, free from colic, refused to undergo retrograde intrarenal surgery. Spondylodiscitis in the course of urinary infections is a consequence of hematogenous spread of infection [3]. A secondary spondylodiscitis related to Enterobacter cloacae septicemia Figure 1. Sagittal T2-weighted magnetic resonance imaging obtained 2 weeks after extracorporeal shock wave lithotripsy for kidney stones complicated by Escherichia coli septicemia. Image shows increased signal intensity of L3–L4 and L4–L5 discs and adjacent vertebral bodies. The features indicate ongoing spondylodiscitis.

A woman in her 70s had right renal colic for 3 months. On 9 December 2020, she consulted a urologist at a regional hospital. Clinical examination showed negative results, while abdominal ultrasound revealed a 16-mm right pyelic stone. Urinalysis performed on 12 December 2020 revealed leukocyturia and microhematuria. On 16 February 2021, the consentient patient underwent ESWL. The early post-operative course was uneventful. Thirtysix hours after the procedure, she experienced a fever with rigor and chills and progressive onset of lumbar pain. Home therapy with oral cefixime was unsuccessful, and she was re-admitted to the hospital 7 days after ESWL (23 February 2021). Increased white blood cells (11 600/μl), serum procalcitonin (19.84 ng/ml) and C-reactive protein (14.72 mg/dl) were detected. Hemoculture was positive for extended-spectrum beta-lactamases producing Escherichia coli, resistant to beta-lactamine and ciprof loxacin. Abdominal computerized tomography showed the unmodified stone. Hydronephrosis was not detected. Intravenous perfusion of gentamycin and co-trimoxazole allowed resolution of the sepsis in 5 days. The patient continued to take oral co-trimoxazole for a week after hospital discharge. In the meantime, the lumbar pain increased in intensity, which led her to consult a neurosurgeon at our university hospital. Magnetic resonance imaging (23 February 2021) showed spondylodiscitis at levels L3, L4, L5 (Fig. 1), which was treated with a cycle of parenteral antibiotics according to the modality described above. The patient was also fitted with an orthopedic brace, which gave complete relief of pain in 1 month. She was made aware of the possible occurrence over time of clinical and imaging features of lumbar stenosis as a consequence of vertebral and discs post-spondylodiscitis deformity. Weight loss and swimming were recommended. Eighteen months after ESWL, the patient was asymptomatic and presented only a modest limitation of lumbar spine motility. Regarding the stone, the patient, free from colic, refused to undergo retrograde intrarenal surgery.
Spondylodiscitis in the course of urinary infections is a consequence of hematogenous spread of infection [3]. A secondary spondylodiscitis related to Enterobacter cloacae septicemia Figure 1. Sagittal T2-weighted magnetic resonance imaging obtained 2 weeks after extracorporeal shock wave lithotripsy for kidney stones complicated by Escherichia coli septicemia. Image shows increased signal intensity of L3-L4 and L4-L5 discs and adjacent vertebral bodies. The features indicate ongoing spondylodiscitis. manifesting after ESWL for urethral stone was observed by Kamanli et al. [4]. However, in that case, urinary tract infection and obstructive uropathy caused by stones were pre-existent to ESWL [4]. Even the spondylodiscitis was probably pre-existent, so that its nexus with ESWL is completely uncertain [4]. Differently from the observation of Kamanli et al. [4], in our patient, the absence of obstruction of the urinary tract (possible pavulum of bacteria), and of urosepsis, implied that septicemia was a consequence of the bacterial spread triggered by ESWL. However, a latent pre-ESWL urinary tract infection cannot be excluded on the basis of the previous leukocyturia.
Pre-ESWL urine culture is mandatory [5]. Spondylodiscitis after complicated ESWL is an extremely rare possibility. Early diagnosis/treatment may result in the prevention of epidural/subdural/intramedullary abscess and/or minimization of disc space narrowing and bony destruction [3], this limiting the risk of lumbar stenosis occurrence.

CONFLICT OF INTEREST STATEMENT
There is no conf lict of interest.

FUNDING
There was no funding for this publication.

CONSENT
Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient.

GUARANTOR
Pasquale Gallina, MD, is the guarantor for this publication.